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digital.ahrq.gov/organization/sarah-bush-lincoln-health-center
January 01, 2023 - Sarah Bush Lincoln Health Center
Ambulatory Electronic Medical Record and Shared Access - 2009
Principal Investigator
DeLuca, Michael
Project Name
Ambulatory Electronic Medical Record and Shared Access
Ambulatory Electronic Medical Record …
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digital.ahrq.gov/organization/hawaii-primary-care-association
January 01, 2023 - Hawaii Primary Care Association
Holomua Project Improving Transitional Care in Hawaii - 2009
Principal Investigator
Sakuda, Christine M.
Project Name
Holomua Project Improving Transitional Care in Hawaii
Holomua Project-Improving Patient H…
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www.ahrq.gov/patients-consumers/patient-involvement/navigating-the-health-care-system.html
September 01, 2015 - Navigating the Health Care System
After having led AHRQ for a decade, Dr. Carolyn Clancy left the Agency in 2013 to begin work as Assistant Deputy Undersecretary for Health, Patient Safety, Quality, and Value at the Veterans Administration. First and foremost a physician, Dr. Clancy was at AHRQ for 23 years.
…
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psnet.ahrq.gov/node/44272/psn-pdf
November 06, 2015 - Technology, cognition and error.
November 6, 2015
Coiera E. Technology, cognition and error. BMJ Qual Saf. 2015;24(7):417-22. doi:10.1136/bmjqs-2014-
003484.
https://psnet.ahrq.gov/issue/technology-cognition-and-error
Providers and policymakers have raised concerns about risks associated with health information
t…
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psnet.ahrq.gov/node/46921/psn-pdf
May 02, 2018 - Medication errors: the school nurse as second victim.
May 2, 2018
Stillwater AR. Medication Errors: The School Nurse as Second Victim. NASN School Nurse.
2018;33(3):163-166. doi:10.1177/1942602x17747294.
https://psnet.ahrq.gov/issue/medication-errors-school-nurse-second-victim
Second victims can be found in a vari…
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psnet.ahrq.gov/node/46082/psn-pdf
February 25, 2019 - The opioid crisis: can improving diagnosis help solve the
problem?
February 25, 2019
Carr S. ImproveDx. April 2017;4:1-4.
https://psnet.ahrq.gov/issue/opioid-crisis-can-improving-diagnosis-help-solve-problem
The opioid epidemic has been widely discussed, but little research has examined how misdiagnosis can
contr…
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psnet.ahrq.gov/node/34747/psn-pdf
August 04, 2009 - The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance. 2nd ed.
August 4, 2009
Langley GJ, Moen R, Nolan KM, et al. Hoboken, NJ: Jossey-Bass; 2009. ISBN: 9780470430880.
https://psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance-
2nd-ed
Effec…
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psnet.ahrq.gov/node/47289/psn-pdf
October 24, 2018 - ASHP guidelines on managing drug product shortages.
October 24, 2018
Fox ER, McLaughlin MM. ASHP guidelines on managing drug product shortages. Am J Health Syst Pharm.
2018;75(21):1742-1750. doi:10.2146/ajhp180441.
https://psnet.ahrq.gov/issue/ashp-guidelines-managing-drug-product-shortages
Drug shortages are a pe…
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/useful.html
July 01, 2018 - AHRQ Program Management Tools
Child Health Care Quality Toolbox
The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.
National Guideline Clearinghouse™
The National Guideline Clearinghouse™ taken down on July 16, 2018, because federal funding t…
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psnet.ahrq.gov/node/864383/psn-pdf
March 13, 2024 - Cyberattack on UnitedHealth still impacting prescription
access: "These are threats to life".
March 13, 2024
Sganga N, Triay A. CBS Evening News. February 29, 2024.
https://psnet.ahrq.gov/issue/cyberattack-unitedhealth-still-impacting-prescription-access-these-are-threats-
life
As health care becomes more technol…
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psnet.ahrq.gov/node/47585/psn-pdf
December 05, 2018 - Insulin pumps have most reported problems in FDA
database.
December 5, 2018
Mohr H, Weiss M. Associated Press. November 27, 2018.
https://psnet.ahrq.gov/issue/insulin-pumps-have-most-reported-problems-fda-database
Usability issues, poor design, and lack of effective instruction hinder safe use of medical equipment…
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psnet.ahrq.gov/node/40985/psn-pdf
December 07, 2011 - Implementing the World Health Organization surgical
safety checklist: a model for future perioperative
initiatives.
December 7, 2011
Styer KA, Ashley SW, Schmidt I, et al. Implementing the World Health Organization surgical safety
checklist: a model for future perioperative initiatives. AORN J. 2011;94(6):590-8.
…
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psnet.ahrq.gov/node/60205/psn-pdf
April 08, 2020 - How should U.S. hospitals prepare for Coronavirus
disease 2019 (COVID-19)?
April 8, 2020
Chopra V, Toner E, Waldhorn R, et al. How Should U.S. Hospitals Prepare for Coronavirus Disease 2019
(COVID-19)? Ann Intern Med. 2020;172(9):621-622. doi:10.7326/m20-0907.
https://psnet.ahrq.gov/issue/how-should-us-hospitals-p…
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psnet.ahrq.gov/node/72535/psn-pdf
December 02, 2020 - Learning from influenza vaccine errors to prepare for
COVID-19 vaccination campaigns.
December 2, 2020
ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.
https://psnet.ahrq.gov/issue/learning-influenza-vaccine-errors-prepare-covid-19-vaccination-campaigns
Safety professionals enco…
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psnet.ahrq.gov/node/44420/psn-pdf
August 26, 2015 - Obstetric safety and quality.
August 26, 2015
Pettker CM, Grobman WA. Obstetric Safety and Quality. Obstet Gynecol. 2015;126(1):196-206.
doi:10.1097/AOG.0000000000000918.
https://psnet.ahrq.gov/issue/obstetric-safety-and-quality
Obstetric hospital admission has substantial potential for harm should something go wr…
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digital.ahrq.gov/sites/default/files/docs/page/THQITStoriesWeissman2010.pdf
December 31, 2007 - In response to this issue and to increase patient safety, two
health plans in Massachusetts helped physicians … with the lowest cost sharing appear in
green, more expensive medications still covered by the health
plans
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digital.ahrq.gov/sites/default/files/docs/page/ImprovingQualityofHealthcareThruHIE.pdf
January 01, 2007 - Engagement of
hospitals, health plans, employers, and primary care physicians is up considerably from … outreach through hospital systems, medical societies,
quality improvement organizations or health plans … structures and organizations, advancement in the
development and implementation of business plans … engages multiple stakeholders, including clinicians, consumer and patient groups, employers,
health plans
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digital.ahrq.gov/sites/default/files/docs/page/Frisse.ppt
June 08, 2005 - Working-Group
Volunteer eHealth Initiative
Starting Points
Medicaid
Uninsured
Employers
Plans … government => Driven by Medicaid costs
The financial transaction infrastructure
Left to the market and plans … infrastructure
Modeled on a “hybrid” version of the Indianapolis work
The last mile
Left to the market and plans … initiatives
Threats to sustainability will require greater commitment from employers, other payers, and plans
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digital.ahrq.gov/sites/default/files/docs/page/Keenan.ppt
January 01, 2004 - Planning Methodology (Pre- GO LIVE)
RN Objectives:
Successfully creates admission and update care plans … anonymous error reporting
Enter 1) nurse shift info, 2) patient care time
Use your submitted Care Plans … Refer to historical care plans and patient progress noted across time, explain rationale
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digital.ahrq.gov/sites/default/files/docs/page/2006Welebob_051711comp.pdf
June 06, 2006 - Engaging health plans- 74% of
respondents perceived the engagement
of health plans as a very difficult … as they get defined
June 6, 2006 Page 14
Key Take-aways
• Engaging your purchasers and health
plans